LOGOPEDIC INTERVENTION IN OROPHARYNGIAN DISPHAGIA OF NEUROLOGICAL NATURE

Abstract

The main objectives focus on an early identification of the risks the patient suffering from disphagia may face and on the application of aspirations, by means of different evaluation methods which will grant safety to the subject [3,4]. The symptoms of oropharyngian disphagia include: * cough prior to, during and post-deglutition; * nasal regurgitation of aliments; * dispnea accompanying alimentation; * modificatuons of the vocal timbre (which frequently becomes sweeter); * sensation of intra-oral or pharyngian rests; * difficult control of one's own secretions; * fractioned deglutition; * insufficient production of a suitable labial occlusion; * difficulty in realizing voluntary cough, for removing the foreign bodies present in the vicinity of the vocal tendons. [...]a complete post-treatment rehabilitation may be observed in the facial, glossopharyngian, vagus, hypogloss and spinal cranial nerves. [...]the more severe is the motororal alteration, the longer will be the time required for deglutition, on also considering the amount of food tolerated by the patient, yet without complicating its global development.

Headnote

Abstract

As known, disphagia causes alteration of deglutition, induced by several causes, such as: brain lesions, neurodegenerative diseases, muscular disfunctions, oesophagian tumors or stenoses. Among brain lesions, disphagy of neurological nature is less studied, as a result of the affections it causes in the cranial nerves responsible for swallowing and speech activities, as well as of their influence upon both processes. A timely detection and intervention may reduce the secondary effects of such a malady, known as having negative consequences on the patient, on the quality of his/her life and, equally, on his/ her family or persons directly related to them.

Keywords: disphagia, cranial nerves, logopedic intervention.

1. INTRODUCTION

Numerous neurological disorders may affect the neural structures which control the complex mechanism of oropharyngian deglutition, the so-called oropharyngian disphagia. Functional disphagia has a great impact at social level, once the number of patients in need of special care is increasing. Generally, the symptoms and complications are the consequence of disphagia, which corresponds to certain alterations at sensitive or motor level in the oral and pharyngian stages of deglutition [1,2].

Urgent interventions, such as oro-tracheal intubation or tracheotomia may add new difficulties, so that, in establishing the diagnostic and treatment, participation of a multidisciplinary team is especially important. The main objectives focus on an early identification of the risks the patient suffering from disphagia may face and on the application of aspirations, by means of different evaluation methods which will grant safety to the subject [3,4].

Disphagia is a frequently occurring pathology, yet less known by the population, even if it has a great impact upon the functional capacity, health condition and life quality of the suffering ones. Essentially, it causes difficulties in trasferring the alimentary bolus in the oropharyngian cavity towards the stomach. Anatomically, oropharyngian or oesophagyan disfunctions may appear when, physiologically, the causes may be either structural or functional [5].

The causes may vary, yet the most frequently met ones are cranio-encephalic traumatisms, tumors, oesophagian stenoses, neurodegenerative diseases, cerebro-vascular accidents and muscular disfunctions.

The symptoms of oropharyngian disphagia include:

* cough prior to, during and post-deglutition;

* nasal regurgitation of aliments;

* dispnea accompanying alimentation;

* modificatuons of the vocal timbre (which frequently becomes sweeter);

* sensation of intra-oral or pharyngian rests;

* difficult control of one's own secretions;

* fractioned deglutition;

* insufficient production of a suitable labial occlusion;

* difficulty in realizing voluntary cough, for removing the foreign bodies present in the vicinity of the vocal tendons.

Among the available evaluation methods, mention should be made of fibronasolaringoscopy, videofluoroscopy, manometry, auscultation with a stethoscope, the MECV-V test and different specific protocols for the affected cranial nerves, all offering relevant information on the patient [6].

The test most frequently applied by speech therapists is that controlling the consistency, volume and texture (MECV-V) of aliments. It is recommended in any circumstances related to possible difficulties in swallowing, as it is easy to administrate, reliable, and not limited to a specific number of utilizations per pacient, being thus useful in preventing disphagia-derived complications. The main advantage of the test is that it provides information on the consistency (nectar, honey, pudding) and volume supported by the patient for avoiding subnutrition and dehydration, to which a lower risk of a pneumonia of aspirative nature is added [6].

2.CLINICAL CASE

67 year-old patient with personal antecedents, former smoker, blood hypertension, dislipidemia and severe peripheric arteriopathia.

Hospitalized in the emergency section, the CT made demonstrates the presence of an accumulation in the left paravermian region, opening towards the ventricular system. With symptoms of bleeding and obstructive hydrocephalia, the patient is submitted to a decompression craniotectomy and tracheotomy caused by respiratory insufficiency.

All these require the utilization of a nasogastric probe, even if the final conclusion is that an endoscopic percutaneous gastrostoma would be the best solution.

Intervention plan

Along the 6 month hospitalization, the patient needs isolation and treatment. The therapy was done in three sessions a week, the subject following a rehabilitation program with a gradual modification of exercises' difficulty. In each rehabilitation stage, a series of personalized objectives is applied. Patient's evolution depends on the stages to which he is submitted along the hospitalization period, as surpassing of each independent stage is indispendable.

3.RESULTS

Tables 2 and 3 will compare both the pre- and post-treatment alterations present in each cranian nerve. Following MECV-V administration, the consistency of honey is considered as adequate for stimulating alimentation, reduced to 1 ml, in 4 different boli, administered with a syringe. During the treatment, the patient comes up to 3 ml, 10 boli, within only 1 month and a half. Worth mentioning is the fact that the patient did not receive food orally for 8 months, which explains why rehabilitation is gradual and progressive, using only small amounts of food.

The results obtained after the application of the treatment established according to patient's profile and priorities will be explained in the following, with ""V" standing for correct/ present, ""X" for incorrect/absent and ""+/-" for weakness in execution.

Consequently, a complete post-treatment rehabilitation may be observed in the facial, glossopharyngian, vagus, hypogloss and spinal cranial nerves. The trigeminal nerve requires further performance and treatment, caused by (internal and external) pterigoid nerves weakening, known as responsible for lateralization and rotative movements of mastication. Orofacial sensitivity was wholly recovered, however, at intra-oral level, it still requires advancement towards the medial lingual portion.

Family plays an extremely important role in cases of disphagia, as its members should understand the associated risks, that is why the specializedat staff should instruct them as to the possible alarm signs. Most important of all is a permanent collaboration with the specialists, for the control of the food amounts introduced in the diet, as well as of the perturbating or postural factors, which may alter the safety and efficiency of deglutition [6,7].

A series of signs may be detected by the family of the patient, such as: observance of the extent of activity during alimentation, refusal of eating or of drinking, fear of remaining alone during eating, avoidance of certain aliments or even fever with unknown causes [8,9].

4.CONCLUSIONS

Disphagia of neurological nature is an alteration of deglutition or of alimentation, caused by a pathology or by a neurological traumatism. Neurological disfunctions may affect the muscular action responsible for the transport of the alimentary bolus from the intra-oral cavity towards the oesophagus. Consequently, the more severe is the motororal alteration, the longer will be the time required for deglutition, on also considering the amount of food tolerated by the patient, yet without complicating its global development.

In the pathologies of neurological nature, a significant loss of cough's sensitivity is frequently observed, as an effect of its own pathology, as well as of chronic aspiration. Efficiency of deglutition is closely related to the voluntary stages, supporting the hypothesis which explains the importance of the cognitive competence, accompanied by subject's motivation, improvements in his/her alimentation being observed [10,11].

Evaluation of the patient and interpretation of the difficulties related to bolus'preparation, to its swallowing or to the presence of rests in the oral cavity are important. Once these characteristics are identified, it is recommended to contact a speech therapist for a clinical exploration of the case, for a correct intervention as to its safety, on using suitable instruments for determining the diagnostic, as well as therapeutical manoeuvres, or even for modifying the volume, consistency, and texture of the diet [12].

References

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